The evidence that voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men is clear. Therefore the Department of Health must set ambitious targets for the roll-out of circumcision in the new National Strategic Plan.

The roll-out of circumcision must be respectful of human rights and consistent with the South African Constitution. Circumcision must be voluntary and only carried out with informed consent.

Government must ensure that legislation allows infants to be circumcised with parental consent.

Guidelines and policies for VMMC must be finalised and widely circulated.

VMMC targets must be properly costed and budgeted for, and expenditure must be monitored.

Traditional circumcision that is funded through the national HIV budget must be safe and provide the same level of protection as medical circumcision. It must also provide the same package of services, including counselling, education, HIV testing and condom distribution.

Government should halt the use of any devices that have not been approved by the World Health Organisation including the Tara KLamp and the AlisKlamp. The suspicious procurement of the Tara KLamp by the KwaZulu-Natal government must be investigated.

We are concerned about the quality of informed consent at mass circumcision camps. We believe these camps should be halted. VMMC must be carried out methodically and properly without shortcuts to boost numbers.

Systems for reviewing VMMC sites should be established. These reviews must be carried out by an independent team and all sites providing VMMC should receive visits twice annually.

Introduction

TAC supports voluntary medical male circumcision (VMMC) because of the clear evidence that it reduces a heterosexual man’s risk of contracting HIV. TAC’s previous briefings on VMMC explain this evidence in detail and remain largely correct.[1][2] This briefing highlights the evidence that has emerged from follow up trials.

After the closure of the randomised control trial in Orange Farm that demonstrated a 60% reduction in risk of contracting HIV for circumcised heterosexual men[3], a follow up trial was carried out to research the uptake of VMMC and the effect of VMMC on sexual behaviour and HIV incidence. Between 2007 and 2010, VMMC was provided freely in the Orange Farm community, along with HIV counselling, testing and condom distribution. The intervention was supported with community education.

The follow up trial showed that a large VMMC programme can be provided safely with very few adverse events. Of the 25,000 circumcisions carried out only 10 hospitalisations occurred, all of which were resolved with no permanent injuries.[4]

The follow up study also found high take-up of VMMC by adolescent and adult men. Between 2007 and 2010, the proportion of men circumcised in Orange Farm rose from 16% to 50%. For males between 20 and 24, this figure rose to 59%.

Some people are worried that circumcised men will have less safe sex in the knowledge that they are less likely to contract HIV. This is called risk compensation. An important finding of the study was that there was no risk compensation effect.

Finally, in comparing HIV incidence and prevalence in men that were circumcised versus men that were uncircumcised, the researchers concluded that HIV prevalence would have been 25% higher and incidence 58% higher if VMMC was not available in Orange Farm.[5]

Another follow up study was carried out in Kenya after the closure of a randomised control trial in 2006. All men who participated in the control arm of the trial were offered VMMC. Follow up at 54 months found that circumcised men reduced their risk of contracting HIV by 63%, demonstrating that the benefit of circumcision is durable.[6][7]

These trials show that a large scale roll-out will likely reduce new HIV infections. If properly planned it can be provided safely many men will chose to be circumcised.

Government’s commitment to expanding VMMC

The roll-out of VMMC in South Africa’s public health system started in April 2010. By July 2011, the Department of Health (DoH) reported that more than 140 000 men were medically circumcised as a result of the initiative. The DoH has developed implementation guidelines for medical practitioners. However, these guidelines have not been widely circulated, as the current format of the electronic document is too large and consequently difficult to email or upload. The DoH should resolve this simple technical issue in order to make the document easy to distribute or download from the DoH’s website. The full document can be accessed here [INSERT LINK: http://www.tac.org.za/community/node/3187]. A draft national policy for VMMC has also been developed through the South African National AIDS Council. However this draft policy must first be approved by the Minister of Health before it is adopted.

Targets for expanding VMMC access and uptake will be set in South Africa’s next national HIV treatment and prevention policy for HIV - the National Strategic Plan (2012 - 2016). In June 2011 it was reported in the media that government aims to circumcise 5.7 million people, or 80% of men aged 15 – 49, over the next 5 years.[8]

While government aims to provide circumcision to male infants, with the consent of parents, this is not yet available in the public sector because of confused interpretations of the Children’s Act of 2005. Infant circumcision is therefore only currently available in the private sector.

Budgets and expenditure

R260 million has been budgeted for the roll-out of VMMC in 2011/12. It is estimated that this will increase to R350 million by 2013/14. A number of sources have suggested that expenditure against this figure has been low. However, assessing expenditure on VMMC has been extremely difficult. One of the challenges cited by Treasury is that it is difficult to determine precisely what is being spent on VMMC because it requires a number of inputs, such as personnel and theatre time, which are not funded directly through this intervention. For the next National Strategic Plan, the Department of Health must evaluate and clearly define which interventions associated with VMMC will be included in the budget. Furthermore, monitoring and evaluation systems must be developed to assess the success of the intervention.

The Department should consult with the Orange Farm circumcision researchers who have a lot of experience with costing circumcision.

Safety

A well organised monitoring and evaluation programme for VMMC sites needs to be established and implemented. All sites offering and reporting figures and statistics for VMMC should be independently evaluated. The evaluation should include a question and answer component that ensures a correct minimum package of services is offered and voluntary consent is confirmed and documented. The minimum package of services should include: extensive education on the risks and benefits of medical circumcision; education on HIV prevention; one on one counselling; HIV, STI and vitals screening; post operative counselling and condom distribution.

The national circumcision policy will also address traditional circumcision, which is common among South African men as a rite of passage to manhood. The draft circumcision policy document recognises that traditional circumcision often does not provide the same preventative benefit as medical circumcision as the entire foreskin is not always removed. If traditional circumcision is funded through the national HIV prevention budget, then the Department of Health must ensure that these circumcisions are safe and provide the same level of protection as medical circumcision. Traditional circumcision should also provide the same minimum package of services.

Several devices for providing circumcision are currently being tested. Some are being used in South Africa despite insufficient safety and efficacy data. The Tara KLamp is widely used in KwaZulu-Natal and a circumcision camp using the AlisKlamp was recently carried out in the Western Cape. The Tara KLamp has been found to be unsafe and there is not consensus on the safety of the AlisKlamp. Government should immediately halt the use of these clamps and only World Health Organisation approved methods of providing circumcision should be allowed. Further, government should investigate the allegations of corruption around the procurement of the Tara KLamp. [INSERT LINK: http://www.quackdown.info/article/king-car-and-clamp/].

In several places, particularly rural KwaZulu-Natal, circumcision numbers are being boosted by running circumcision camps for young men. We are concerned that these camps do not provide adequate counselling or informed consent. VMMC is necessary, but its implementation must be carried out without shortcuts to boost numbers. Human rights must be respected and VMMC programmes must be consistent with the Constitution. The Orange Farm project has shown how this is possible and yet still reached large numbers of people. The circumcision camps should be stopped.